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PubMed2005

Healing of a scaphoid nonunion using human bone morphogenetic protein.

A chronic nonunion of a proximal pole fracture of the scaphoid was treated by curettage of the nonunion, single K-wire fixation, and implantation of 50 mg of human bone morphogenetic protein followed by 12 weeks of cast immobilization without any conventional corticocancellous bone grafting or rigid screw fixation. Radiographs showed signs of bony healing by 12 weeks and a magnetic resonance imaging scan 6 years after surgery showed no signs of avascular necrosis. The potential future applications of human bone morphogenetic protein in hand surgery are discussed.

Adolescent↗
PubMed1992

The reliability of the 3-phase bone scan in suspected scaphoid fracture: an inter- and intraobserver variability analysis.

In the diagnosis of scaphoid fracture, the dynamic phase of the radionuclide bone scan alone has been recommended as an early test. To evaluate the independent reliability of the dynamic and static phases of the 3-phase bone scan in this diagnosis, 3 examiners reviewed the 3-phase bone scans of a series of 60 patients with clinical signs of fracture of the carpal scaphoid and with negative or non-diagnostic initial radiographs. The interpretation was performed independently and without the benefit of additional data. The bone scans were reviewed after 1 year by the same observers. The results were analyzed using kappa statistics. The bone scan was suspicious of fracture of the scaphoid in 15 patients. Irrespective of training and experience, the kappa values of the dynamic bone scan between any 2 observers did not exceed 0.57. The kappa values increased significantly when the static phase of the bone scan was examined (> 0.81). The intraobserver variability showed a similar pattern. We conclude that in suspected scaphoid fracture, the dynamic phase of the radionuclide bone scan alone cannot be used as a reliable diagnostic approach because of the low inter- and intraobserver agreement in the interpretation, irrespective of the experience and training of the observer.

Adult↗
PubMed1985

[Scapholunate dissociation].

Scapholunate dissociation is a rotatory subluxation of the scaphoid with widening of the gap between the scaphoid and lunate. It is caused by rupture of the ligaments between radius, scaphoid, lunate and capitate bones. The scaphoid has lost its stabilizing function as a bridge between the proximal and distal carpal row, so that the wrist shows the typical "concertina" deformity of dorsal instability. The scapholunate angle measures about 100 degrees (more than 70 degrees). The subluxation of the scaphoid and lunate with the wide gap between these bones is best treated by primary repair of the ruptured ligaments. However, most cases are seen late and a ligament reconstruction by a free or pedicled tendon graft becomes necessary. The results are often unsatisfactory radiologically, but cause the patient minimal disability. An alternative to the ligament reconstruction is the scapho-trapezio-trapezoid arthrodesis. By this procedure the scaphoid regains its stabilizing function to the "link system" of the carpus.

Arthrodesis↗
PubMed1995

Plain film evaluation of bone grafting for nonunited scaphoid fractures.

OBJECTIVE: To determine how the appearance of fracture line bridging and graft incorporation changed on sequential plain films obtained during the healing of successful grafts for scaphoid nonunion. DESIGN: We identified 50 patients who had healed Russe bone grafts for nonunited scaphoid fractures. These patients had 214 sets of wrist radiographs obtained 1-36 months after surgery. Each set of radiographs was reviewed in random order by two observers who were blinded as to the patient's name and the time interval since surgery. Closure of the fracture line and the presence of a linear lucency in each of six zones surrounding the graft were assessed using a three-point grading scale. PATIENTS: Forty-six men and four women were included in the study. Their mean age was 30 years with a range from 21-43 years. RESULTS AND CONCLUSIONS: With increasing time after surgery, there was progressive fracture line closing and disappearance of linear lucencies at the interfaces between the scaphoid and the graft. However, a 20% of the patients had a well-defined lucency in at least one of the six zones around the graft on their last film. Even 1 year after surgery, the fracture line showed no bridging on the radial side in 22% of patients and on the ulnar side in 11%. We conclude that after grafting, most scaphoid nonunions show progressive fracture line closure and graft incorporation. However, the fracture line may not completely close and lucencies may persist in several zones around the graft for more than 1 year. These radiographic appearances should be recognized as part of the normal spectrum of healing.

Adult↗
PubMed1999

Osteosynthesis of carpal scaphoid nonunion with interpositional bone graft and Kirschner wires: a 3- to 6-year follow-up.

BACKGROUND: Malreduced or neglected unstable carpal scaphoid fractures may lead to nonunion, which is often difficult to treat and carries the risk of carpal instability and degenerative arthrosis. Here, we describe a new "sandwich" method, which takes advantage of minimal dissection and has promising results. METHODS: From 1989 through 1992, we treated 39 patients with scaphoid nonunion by using the sandwich method that consisted of a wedge corticocancellous strut graft and numerous cancellous bone chips. Divergent Kirschner wires were used for fixation of reduction. We retrospectively review 26 scaphoids with follow-up periods of 3 to 6 years. The functional outcome was evaluated with modification of the Mayo Wrist Scoring Chart. The radiographs were analyzed, and tomographs were used for confirmation of osseous union. RESULTS: All 26 scaphoids united within 4 months. The carpal instability and humpback deformity were corrected. In all cases, the functional results were either good or excellent. CONCLUSION: Interpositional bone grafts corrected scaphoid angulation and length. Divergent multiple pinning rather than screws avoids unwanted shearing and rotational force during application and provides stable fixation with minimal dissection. Most of scaphoid nonunions in our series were the oblique type in which the lag screw never created perfect compression because of a shearing force.

Adolescent↗
PubMed1992

Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid.

Twenty-five patients had Russe anterior corticocancellous bone-grafting between 1973 and 1984 for twenty-six symptomatic established non-unions of the scaphoid. The mean duration of follow-up was eleven years (range, seven to eighteen years). Twenty-one (81 per cent) of the twenty-six scaphoid bones united. We developed two rating scales to evaluate the results of the operation. One scale, based on objective findings, included the radiographic appearance of the wrist, the range of motion, and strength; the other scale, based on subjective findings, comprised function, pain, perception of a decrease in performance because of limitation of motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had a malunion of the scaphoid in which the lateral intrascaphoid angle was more than 45 degrees convex dorsally between the proximal and distal poles (a so-called flexion or humpback deformity, which results in extension of the proximal fragment of the scaphoid at the radiocarpal joint) with the results in patients who had no such deformity. The lateral intrascaphoid angle was more than 45 degrees in thirteen (50 per cent) of the twenty-six wrists. Although the difference in the objective results between the wrists that had a malunion and those that did not have a malunion was highly significant (p = 0.001), there was no significant difference in the subjective results between the two groups, including satisfaction of the patient (p = 0.39). Twenty-three patients (92 per cent) returned to full-time employment and twenty-two (88 per cent), to sports activities. Twenty-three patients (92 per cent) reported that they had pronounced relief of pain and that the procedure had improved their quality of life. The presence of this deformity of the scaphoid after bone-grafting for a symptomatic non-union was not predictive of a poor long-term subjective outcome.

Adolescent↗
PubMed1989

[Treatment of fractures of the carpal scaphoid with Herbert's bone screw. Review of 21 clinical cases].

Twenty-one patients with scaphoid fractures treated by internal fixation with the Herbert screw are reviewed. Nine patients presented acute fractures and twelve had fractures with delayed or non-union. The results of these two kinds of lesions are analyzed following the criteria established by Herbert and Fisher in 1984. This type of internal fixation gives excellent results in isolated lesions of the scaphoid provided it is correctly executed.

Adolescent↗
PubMed1987

Fractures of the carpus, excluding the scaphoid.

Carpal bone fractures comprise an important group of injuries that present difficulties in both diagnosis and treatment. These fractures may be missed for the following reasons: physician's low index of suspicion, the carpal bones' irregular contours and degree of overlap on radiographs making the fractures difficult to visualize, and the common occurrence of concomitant fractures of neighboring metacarpals, distal radius, or scaphoid, which misdirects the examiner. A high index of suspicion with careful clinical examination and elicitation of point tenderness is key to making the correct diagnosis (Fig. 14). Swelling, loss of motion, deformity, and crepitus are often minimal and are not reliable in distinguishing carpal fractures. Specific radiographic projections, tomograms, computerized tomographic scans, or bone scans are often required and should be considered in any wrist injury where the diagnosis is in question. A greater awareness of the fracture types, methods of diagnosis, and choices of treatment is essential for optimal management of these injuries.

Bone Wires↗
PubMed1995

Repeat Russe bone grafting after failed bone graft surgery for scaphoid non-union.

We report the long-term outcome of repeat Russe bone grafting after failure of a previous Russe graft for scaphoid non-union. 15 patients were followed for a mean of 71 months after their last surgical procedure. 11 patients had undergone a single previous Russe graft and four patients had two previous graft attempts. Internal fixation was used in only three patients. Eight out of 15 (53%) patients achieved union after a single repeat graft and one out of four united after a third attempt. When union was achieved, range of motion was unchanged, grip strength was increased 10% and pain was slight to none, allowing return to full employment in seven out of the nine patients. All patients who did not achieve union have either undergone a salvage procedure or are contemplating one. Based on the literature and our relatively low rate of union without internal fixation (53%), we recommmend supplementary internal fixation if repeat Russe bone grafting is undertaken. When union is achieved, satisfactory results can be expected.

Adolescent↗
PubMed2004

Study of carpal bone morphology and position in three dimensions by image analysis from computed tomography scans of the wrist.

The morphology and positioning of the carpal bones were studied in three dimensions in 18 normal adults on computed tomography (CT) scans of the wrist. The digital data from each CT scan were processed to extract the carpal bones and to automatically characterize their geometry (geometric centroid, principal axes of inertia) using specific software tools. Biometric and angular parameters were defined for this purpose, and most of these parameters showed a normal distribution. The mean distance between the geometric centroid of the capitate and that of the triquetrum, expressed as a relationship to the length of the first principal axis of inertia of the capitate, was found to be the greatest (157.6%+/-8.4%), whereas the smallest mean distance was between the hamate and triquetrum (91.4%+/-7.3%). In the sagittal plane, the first principal axis of inertia of the bones of the first carpal row projected in front of the vertical axis of the orthogonal reference system, whereas the first principal axis of the capitate projected behind it. Measurements using this methodology are far more numerous than those from standard plain radiographs and have the additional advantage of being independent of the examiner. Future investigations on normal wrists should provide a normal range for each quantitative parameter, and comparative study of normal and pathologic wrist measurements should help to define the most relevant parameters for specific traumatic pathologies of the wrist.

Adult↗
PubMed2006

A vascularized technique for bone-tissue-bone repair in scapholunate dissociation.

Several surgical options have been used for the repair of scapholunate instability over the last 50 years. The many options have included neglect, reduction with percutaneous pinning, primary repair, partial fusions, tendon weaves, and others. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiological repair. Composite replacement of the entire scapholunate interval similar to other tendon repairs seen in orthopedic surgery has become popular. Currently, more common hand-based grafts are bone-retinaculum-bone, third or second metacarpal-carpal bone or hamate-capitate grafts. There still exist some failures in the outcome after any of these procedures. This technique demonstrates the use of a vascularized autograft replacement on a pedicled graft. This procedure is the natural extension of the third or second metacarpal-carpal bone autograft, previously reported in the literature. The use of this proven graft, with a pedicle based on the intermetacarpal artery, may avoid some of the late complications seen with other autografts.

Bone Transplantation↗